What is the purpose of a comparative billing report on viscosupplementation (VIS) of the knee?
CBR201616 was created to inform providers about their billing and payment patterns on claims submitted for VIS of the knee. The CBR team reviewed Fee-for-Service (FFS) Medicare claims with dates of service from July 15, 2015 to June 30, 2016. For more general information about CBRs, please visit our website at the link titled, Comparative Billing Reports.
Why was VIS of the knee chosen to be a topic?
This topic was selected because the Centers for Medicare & Medicaid Services (CMS) is questioning the efficacy and cost-effectiveness of hyaluronic acid (HA) injections to the knees. According to a study titled Hyaluronic Acid Injections for Treatment of Advanced Osteoarthritis of the Knee: Utilization and Cost in a National Population Sample, “The results indicated that patients receiving HA injections were significantly more likely to receive additional knee osteoarthritis-related treatments compared with patients who did not receive HA injections." To view details of this study, see the following web link: The Journal of Bone and Joint Surgery.
What Current Procedural Terminology (CPT®) codes and Healthcare Common Procedure Coding System (HCPCS) codes did you analyze for this CBR?
This CBR examines VIS of the knee services billed with HCPCS codes J7321, J7323, J7324, J7325, J7326 and J7327. The report also includes an analysis of CPT® codes for injection services: 20610, 201611, 76881, 76882, 76942, 77002, and established E/M services CPT® codes 99211-99215 billed with VIS of the knee HCPCS codes.
What is the specific focus of CBR201616 and how many providers received CBRs?
CBR201616 was disseminated to 4,100 providers and focuses on providers who submitted claims for VIS of the knee services whose billing and payment patterns were different from their peers. The metrics reviewed in the report include:
- Percentage of visits with injection CPT® code 20611
- Percentage of visits with other injection CPT® codes (76881, 76882, 76942, 77002)
- Percentage of visits billed with established patient E/M CPT® codes
- Average allowed charges per beneficiary
To review an example, see the mock provider’s CBR at the following link: CBR201616 Sample CBR.
Is receiving a CBR an indication that I’m billing incorrectly?
No. Receiving a CBR is not necessarily indicative of incorrect billing; however, it does mean that your billing is different from your peers. There can be many reasons your billing patterns may vary, including region, subspecialty, and patient acuity. If you still have questions and/or concerns after reviewing your CBR, please contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.
Should providers be concerned about impending audits if they received a CBR?
The CBR team does not conduct audits nor have access to medical documentation needed to perform audits of claims. The purpose of CBRs is to inform providers about their billing and payment patterns. It may be beneficial, however, for providers to conduct self-audits. Resources that can help with setting up an audit process are located on our CBR website page at the link titled, Self-Audit Help.
Where can providers find additional Medicare guidelines?
Providers may benefit from the explanations of the Tables in the CBR, which are found at the web link titled, CBR201616 Statistical Debriefing. Additionally, the links for the references and resources used in this CBR are located at CBR201616 Recommended Links.
What is viscosupplementation (VIS) of the knee?
VIS of the knee involves intra-articular hyaluronic acid injections to treat osteoarthritis of the knee. Per First Coast Service Options (FCSO) LCD L33767, Physicians give these injections to patients with pain in their knees “who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDS).” Select the following link for more information: FCSO LCD L33767.
What is osteoarthritis?
Osteoarthritis affects the cartilage in the joints and develops as a result of wear and tear. It develops when the cartilage covering the end of the bones wears away, loses its smoothness and becomes rough and frayed. As a result, the joints can become inflamed and movement can be painful due to the bones rubbing against each other. More in-depth information about osteoarthritis is available on the website of the American Academy of Orthopaedic Surgeons (AAOS) at the web link titled OrthoInfo: Osteoarthritis.
What is the purpose of hyaluronic acid (HA) injections to the knee?
Synovial fluid is made of hyaluronic acid, lubricin, proteinases and collagenases. It is a thick substance that lubricates joints and acts as a shock absorber allowing bones to glide against one another. There is a high content of hyaluronic acid in synovial fluid which makes it very viscous. When synovial fluid is loss, osteoarthritis may occur causing sore or stiff joints, limited range of motion, swelling, clicking or cracking and pain. According to an article on the Arthritis Foundation website, HA injections (replacing hyaluronic acid) may provide some relief and “are one treatment option doctors may offer when a patient is no longer able to control osteoarthritis pain with ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs), or the patient can’t tolerate these drugs (which can cause side effects such as stomach bleeding and kidney problems). The treatment regimen for hyaluronic acid usually involves receiving one injection in the affected joint per week for three to five weeks.” To read the entire article, see the following web link: Hyaluronic Acid Injections for Osteoarthritis.
Do orthopedic physicians recommend HA injections to the knee?
In 2012, the American College of Rheumatology (ACR) took the following Positions:
- The American College of Rheumatology recommends the use of intra-articular hyaluronic acid injection for the treatment of osteoarthritis of the knee in adults in accordance with the ACR 2012 OA guidelines.
- Hyaluronic acid injection is clinically indicated for management of osteoarthritis in patients who are not good candidates or who do not respond to other treatment options.
- The American College of Rheumatology supports patient access to appropriate therapies including hyaluronic acid injection.
To view the complete ACR information, select the following link: American College of Rheumatology Position Statement.
The AAOS has a different opinion than the ACR and “in 2013, the American Academy of Orthopaedic Surgeons (AAOS) released a revised version of its clinical practice guidelines (CPG) for the treatment of knee OA, which no longer recommends intra-articular HA for symptomatic patients. In the two years following this announcement, a number of commercial insurance carriers in the US have started to reverse their policies.” For more details about AAOS guidelines, select the following website link: Viscosupplementation May See More Insurance Denials in 2015.
Is CMS changing its policy coverage of VIS of the knee?
The Agency for Healthcare Research and Quality (AHRQ) Technology Assessment (TA) program has issued a report regarding the effectiveness of hyaluronic acid knee injections. The report published in Orthopedics This Week stated “if the treatment delays arthroplasty but fails to halt progressive degeneration, patients could potentially experience worse outcomes…” As a result of the report, CMS is taking a second look at their national coverage policy for HA. CMS wants to know if VIS “can reduce the rate of knee replacement surgery…and, furthermore, whether they affect knee function, quality of life or pain.” To view the entire report, select the following web link: CMS Takes a Second Look at HA Knee Injections.
Is VIS of the knee still considered medically reasonable and necessary?
According to FCSO LCD L33767, VIS will be reasonable and necessary when, “ALL of the following conditions are met:
- The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness
- The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts
- If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, laboratory and imaging studies (i.e. the pain and functional disability is not considered likely to be due to a diagnosis other than osteoarthritis of the knee.)
- The patient has failed at least three months of conservative therapy. Conservative therapy is defined as:
- Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, physical therapy if indicated); and
- If not contraindicated, simple analgesics and NSAIDS.
- The patient has failed to respond to aspiration of the knee and intra-articular corticosteroid injection therapy when inflammation is a significant component of the patient’s symptoms and intra-articular corticosteroids are not contraindicated.”
To view more information, select the following web link: FCSO LCD L33767.
What criteria should providers use to determine if services are medically necessary if there is no Local Coverage Determination (LCD) for their region?
Reasonable and necessary services are defined in the Medicare Program Integrity Manual and are covered “if the contractor determines that the service is:
- Safe and effective;
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000 which meet the requirements of the Clinical Trials NCD are considered reasonable and necessary); and
- Appropriate, including the duration and frequency that is considered appropriate for the item or service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member;
- Furnished in a setting appropriate to the patient's medical needs and condition;
- Ordered and furnished by qualified personnel;
- One that meets, but does not exceed, the patient's medical need; and
- At least as beneficial as an existing and available medically appropriate alternative.”
Information on reasonable and necessary provisions is available at the following link: Medicare Program Integrity Manual, Chapter 13, Section 13.5.1.
Are any medical reviews being conducted on claims submitted with VIS of the knee CPT® and HCPCS codes?
Yes. FCSO is currently conducting automated and complex medical reviews of VIS of the knee utilization parameters (units billed) for HCPCS codes J7325 and utilization parameter of codes overtime for HCPCS J7321, J7323, J7324, J7325, J7326 or J7327. FCSO is also reviewing imaging procedures for CPT® codes 77012, 77021, 76882 or 76942 billed on the same date of service with HCPCS J7321, J7323, J7324, J7325, J7326 or J7327. To view this information, please visit the FCSO website at the link titled, Notice of Medical Review Topics.
Noridian Healthcare Solutions is conducting a targeted review for “CPT® 20610 - Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa), without ultrasound guidance.” This code is most frequently billed with the viscosupplementation codes. For more details, visit Noridian’s website at Arthrocentesis, 20610 – Widespread Service Specific Targeted Review Notification.
Are payments for HA injections higher than other treatment payments?
Yes. A September 2016 study published by The Journal of Bone and Joint Surgery found that “HA injections accounted for 25.2% of treatment-specific payments, a rate that was higher than that of any other treatment.” Researchers reviewed the databases of different companies from 2005 to 2012 to identify patients who had total knee arthroplasty (TKA) and determined that “patients receiving HA injections were significantly more likely to receive additional knee osteoarthritis-related treatments compared with patients who did not receive HA injections.” To view the complete report, please select the following web link: Hyaluronic Acid Injections for Treatment of Advanced Osteoarthritis of the Knee: Utilization and Cost in a National Population Sample.
What did this study conclude about HA injections?
The study concluded that it may be cost-effective to decrease HA injections. Per the report, “HA injections are still utilized for a substantial percentage of patients. Given the paucity of data supporting the effectiveness of HA injections and the current cost-conscious health-care climate, decreasing their use among patients with end-stage knee osteoarthritis may represent a substantial cost reduction that likely does not adversely impact the quality of care.” Providers may view the conclusions of the report at the link, Hyaluronic Acid Injections for Treatment of Advanced Osteoarthritis of the Knee: Utilization and Cost in a National Population Sample.
How was the data obtained for this report?
This report is an analysis of Medicare Part B claims with allowed services for the HCPCS/CPT®
codes listed in Table 1 with dates of service from July 1, 2015 to June 30, 2016, and include only those claims where the place of service is denoted as specialty 11. Additionally, only those claim lines with a diagnosis of osteoarthritis of the knee were used in this report. This analysis was based on the latest version of claims available from the Integrated Data Repository (IDR), as of October 4, 2016. For more information about the IDR, see the following link: CMS Integrated Data Repository (IDR).
How were providers selected to receive CBRs?
CBR data team analyzed Medicare Part B claims with allowed services for the CPT® and HCPCS codes, and identified those providers (specialty 11) with different billing patterns than their peers. Approximately 4,100 providers were selected to receive reports. Providers who did not receive a CBR and would like to view a mock report can see one at the following link: CBR201616 Sample CBR.
How are the peers defined?
Each billing provider was identified by their National Provider Identifier (NPI), which is supplied by NPPES. The peer groups that are used for comparison with individual providers were identified as follows:
- State: All Medicare providers located in the provider's state with allowed charges for the CPT® codes and HCPCS codes covered in this CBR
- National: All Medicare providers in the nation with allowed charges for the CPT® codes and HCPCS codes covered in this CBR
What do the comparison outcomes mean?
The four possible outcomes for the comparisons between the provider and peer groups are:
- Significantly Higher - provider’s value is higher than the peer value and the statistical test used confirms significance
- Higher – provider’s value is higher than the peer value, but either the statistical test does not confirm significance or there is insufficient data for comparison
- Does Not Exceed - provider’s value is not higher than the peer value
- N/A (Not Applicable) - provider does not have sufficient data for comparison
What is the meaning of Table 1?
Table 1 lists the Category, CPT®/HCPCS Codes, and Abbreviated Descriptions. To review an example of a mock provider’s report, follow the web link at CBR201616 Sample CBR.
What does Table 2 show?
Table 2 is a Summary of Your Utilization for Codes and shows the mock provider’s use of CPT® and HCPCS codes covered in this CBR. This table lists the HCPCS/CPT® codes, Allowed Charges, Allowed Services, Visit Count and Beneficiary Count. It is possible for a single visit to be billed with multiple HCPCS and/or CPT® codes. To see a sample report, select the web link titled, CBR201616 Sample CBR.
What’s the significance of Table 3?
Table 3 is a comparison of the mock provider’s Percentage of Visits with Injection CPT® Code 20611. This measure was selected to provide comparisons on the use of guided imaging codes, as these procedures are used routinely for the purpose of providing guidance for needle placement and are not covered. This table shows how your results compare to your peers in this area. To illustrate this, refer to Table 3 of the mock provider’s CBR at the following link: CBR201616 Sample CBR. In this example, this provider’s percentage is 100 percent. The state’s percentage is 36 percent, and the national percentage is 18 percent. This provider’s percentage is Significantly Higher than the state percentage and is Significantly Higher than the national peer group. To view the results for all states and the nation, select the following link: CBR201616 Statistical Debriefing.
How should providers interpret Table 4?
Table 4 is an analysis of the Percentage of Visits with Other Injection CPT Codes (76881, 76882, 76942, and 77002). This measure was selected to provide comparisons on the use of guided imaging codes, as these procedures are used routinely for the purpose of providing guidance for needle placement and are not covered. This table shows how your results compare to your peers in this area. For an illustration, refer to the mock provider’s CBR on our website link at CBR201616 Sample CBR. In this example, this provider’s percentage is 0 percent. The state’s percentage is 11 percent, and the national percentage is 11 percent. This provider’s percentage Does Not Exceed that of the state percentage and also Does Not Exceed that of the national peer group. To review the results for each state and the nation, see the following link: CBR201616 Statistical Debriefing.
What does the analysis mean in Table 5?
Table 5 is an example of the Percentage of Visits with Established Patient E/M. This measure was selected to provide comparisons on the use of E/M codes along with injection codes. If performed on the same date of service as the minor procedure, they are included in the payment for the procedure. This table shows how your results compare to your peers in this area. In this example, this provider’s percentage is two percent. The state’s percentage is 17 percent and the national percentage is 19 percent. This provider’s percentage Does Not Exceed that of the state and also Does Not Exceed that of the national peer group. To review the results for each state and the nation, see the following link: CBR201616 Statistical Debriefing.